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Silence of the PPOs: A stealthy way to pay you less

A "silent PPO" is actually a process in which physicians suddenly find themselves on a health plan they didn't sign up for. And it's bigger than ever. Here's why, and what physicians can do about it.

By Bob Cook, amednews staff. Sept. 19, 2005.

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Silent PPOs are the leaky faucet of the health plan world. They drip, drip, drip money away from physicians' practices, slowly enough that it seems as if fixing the leak is not worth the expense.

But a leaky faucet eventually turns into a running faucet, which turns into a gusher. And that's what's starting to happen with silent PPOs. Organized medicine, including the American Medical Association, is reporting a skyrocketing number of complaints about silent PPOs, a term used to describe when physicians think they're treating a patient under one contract, only to get a statement later that puts the patient on some other, lower-reimbursing plan. The AMA estimates anywhere from a $750 million to $3 billion annual loss to physicians caused by silent PPOs.

Fixing the leak is now very much worth it. Organized medicine has launched campaigns for increased state regulation or legislation aimed at unsilencing the silent PPOs.

"It's an issue of fairness," said J. James Rohack, MD, the AMA's immediate past board chair, who in the past few months has spoken before the National Assn. of Insurance Commissioners and the National Council of Insurance Legislators on silent PPOs, among other contract issues.

Silent PPOs are not making health care more affordable, but instead are "taking money out of what could be paid for health care. ... It's affecting the doctors, and it will affect more and more the citizens of every state. It's a system that's evolved to be difficult to understand and shrouded in secrecy," he said.